National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 6: Eye health
Visual acuity

Recommendations: Visual acuity
Preventive intervention type	Who is at risk?	What should be done?	How often?	Level/ strength of evidence	References
Screening	Infants	Conduct a general eye examination. Refer to an ophthalmologist if the red reflex is absent or any other abnormality is found, Screen for visual acuity Refer if visual acuity is less than 6/9 in either eye for a three-year-old and 6/9 or less in either eye for a 4–6-year-old	Before three months of age and again between three and six months of age As part of a routine health assessment at or before school entry	GPP GPP	^15,^16,^17, ⁶⁷
	Children aged 3–5 years			GPP GPP	^15,^16,^17, ⁶⁷
	All age groups	Ask about vision. Complete an eye examination and test visual acuity if any problems are identified. Include testing for near visual acuity from age 40 onwards. Refer to an optometrist and/or ophthalmologist if problems are identified	Every 1–2 years as part of a routine health assessment	GPP	^7,^19, ²⁰
	People with diabetes	Undertake visual acuity and retinal assessment by a trained assessor This includes the use of retinal photography by trained primary healthcare staff combined with external review by an ophthalmologist	Yearly	IA IA	⁵⁰ ^{57, 58,} ⁵⁹
	Pregnant women with pre-existing diabetes	Conduct an eye examination and counsel clients about the risks of diabetic retinopathy (DR)	Prior to conception	III–2B	^52, ^53, ^61, ⁶⁶
		Conduct an eye examination by dilated fundus examination or retinal digital imaging	In the first trimester	III–2B	^50, ^52, ^53,⁶⁶
		The need for further retinal examinations should be guided by results of earlier examinations	In the second and third trimesters	IV	^50, ^52, ^53, ⁶⁶
		Provide ongoing ophthalmic follow-up in the post-partum period	For 6–12 months postpartum Opportunistic	III–2B IIIC	^52, ^53, ⁶¹ ³⁸
Behavioural	People who currently smoke	Advise smoking cessation to reduce the risk of developing cataracts (refer to Chapter 1: Lifestyle, ‘Smoking’)	For 6–12 months postpartum Opportunistic	III–2B IIIC	^52, ^53, ⁶¹ ³⁸
	All people	Recommend reduced ocular exposure to ultraviolet B light to reduce risk of cataract (eg wearing a hat and sunglasses when outdoors)	Opportunistic	IIIC	^38, ^68, ⁶⁹
	All people	Recommend a balanced diet high in fruit and vegetables to reduce the risk of developing cataract and age-related macular degeneration	Opportunistic	IIB	³⁷

Background

Eye health is critical to quality of life. In 2016, more than 453,000 Australians were living with vision impairment or blindness. Based on the 2016 National Eye Health Survey (NEHS) and age-adjusted population data, it is estimated that this includes up to 18,300 Aboriginal and Torres Strait Islander people aged 40 years or older.¹ Approximately 90% of vision impairment and blindness among both Aboriginal and Torres Strait Islander people and non-Indigenous Australians is preventable or treatable.¹ In the 2016 NEHS, a person with vision impairment was defined as having visual acuity between <6/12 and 6/60 in the better eye and a person with blindness was defined as having visual acuity <6/60 in the better eye.¹

Impaired vision often goes unrecognised and contributes significantly to morbidity.² The National Indigenous Eye Health Survey (NIEHS) in 2009 reported eye/sight problems as the most common self-reported longterm health condition.^3,4 In the elderly, visual impairment is a risk factor for falls, hip fractures, depression, social and functional decline and increased mortality.^5–10 An association between visual impairment and increased mortality has also been shown in Aboriginal people in Central Australia.¹¹

The age-adjusted prevalence of vision impairment in Aboriginal and Torres Strait Islander peoples is 13.6%, three times higher than rates for non-Indigenous Australians.¹ Similarly, the age-adjusted prevalence of blindness in Aboriginal and Torres Strait Islander peoples is three times higher compared to non-Indigenous Australians (0.36% versus 0.12%).¹ These rates are even higher in Aboriginal peoples in Central Australia.¹² The highest prevalence of vision impairment in Aboriginal and Torres Strait Islander peoples occurs in outer regional areas. By contrast, vision impairment in non-Indigenous Australians does not exhibit a substantive regional variation.¹

The main causes of vision impairment in both Aboriginal and Torres Strait Islander peoples and nonIndigenous Australians are uncorrected refractive error (approximately 60% in both Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians) and cataract (20.2% in Aboriginal and Torres Strait Islander peoples and 13.9% in non-Indigenous Australians). This highlights that approximately 80% of vision impairment is treatable with spectacle correction or cataract surgery.¹ In the 2009 NIEHS, over a third of participants (39%) could not read normal size print, and 62% reported they normally wore reading glasses for near-work (eg reading, sewing).⁴ Of those with near-vision impairment, 37% reported not having near-vision correction.¹³ Diabetic retinopathy (DR) as a cause of vision impairment in Aboriginal and Torres Strait Islander peoples is more than three times more prevalent than in non-Indigenous Australians (5.5% versus 1.5% respectively). Age-related macular degeneration and glaucoma are relatively uncommon and account for 1.1% and 0.65% respectively of vision impairment in Aboriginal and Torres Strait Islander peoples.¹

The main cause of blindness in Aboriginal and Torres Strait Islander peoples is cataract (40%).¹ Other causes include diabetic retinopathy (20%), optic atrophy (20%) and a combination of mechanisms (20%).¹ The primary cause of bilateral blindness in non-Indigenous Australians is age-related macular degeneration (71.4%).¹ The NIEHS showed that uncorrected refractive error is also an important cause of blindness in Aboriginal and Torres Strait Islander peoples (14%), five times higher than in non-Indigenous Australians, and trachoma still contributes significantly to blindness in Aboriginal people, particularly in Central Australia.^3,12 Around 6% of Aboriginal and Torres Strait Islander people in the NIEHS with vision loss were newly identified and had not had the condition diagnosed previously.¹

Cataract surgery occurs less often in Aboriginal and Torres Strait Islander people than in non-Indigenous Australians (61.5% versus 87.6%),^1,14 and treatment coverage of refractive error in Aboriginal and Torres Strait Islander people is 83.3% compared with 93.7% in non-Indigenous Australians.¹ Only around one half of Aboriginal and Torres Strait Islander people with self-reported diabetes report having undergone a diabetes eye examination within the last year, as recommended by National Health and Medical Research Council (NHMRC) guidelines, with significantly lower rates of eye examination in very remote areas.¹

Interventions

Evidence for the effectiveness of preventive interventions

Vision screening in children

Available literature and many professional guidelines generally recommend a check for congenital eye conditions within the first three months of life.¹⁵ The project advisory group from the National Children’s Vision Screening Project (NCVSP) in 2009 also recommended vision assessments for children between the ages of three and six months.^16,17
For older children, the NCVSP, two recent Australian reviews and the US Preventive Services Task Force
(USPSTF) recommend vision screening at least once between the ages of three and five years.^15–17,67 Screening should aim to detect diminished visual acuity, and follow-up screening and treatment should be available for those who require it. Referral criteria are dependent on the age of the child and include a visual acuity less than 6/9 in either eye for a three-year-old and 6/9 or less in either eye for a 4–6-year-old.¹⁵

In Australia, the prevalence of amblyopia in children ranges from 1.4% to 3.6%, while strabismus ranges from 0.3% to 7.3% and refractive error ranges from 1% to 14.7%. Aboriginal and Torres Strait Islander children are five times less likely to have vision impairment than non-Indigenous children,¹⁶ with less refractive error and strabismus; however, refractive error is the cause of about 50% of visual impairment in Aboriginal and Torres Strait Islander children.⁴ Convergence insufficiency and reduced visual information processing skills appear to be more common in Aboriginal and Torres Strait Islander children when compared to non-Indigenous children.¹⁸

In addition to routine vision screening, Aboriginal and Torres Strait Islander children living in rural and remote areas should be screened for trachoma when there is increased risk.
Further, children with a history of prematurity, birth weight less than 1500 g, and developmental delay or disability, should have more comprehensive eye testing and follow-up as they are at increased risk of vision impairment.¹⁶ In Australia, each state and territory health department has separate guidelines for paediatric vision screening.¹⁷ These guidelines are all generally in keeping with the above evidence.^7,17,19–22

Vision screening in adults

Although there is insufficient evidence to assess benefits and harms of population-based screening for visual acuity in otherwise well adults, visual acuity screening is advocated in older people because refractive errors are correctable with eyeglasses and have good outcomes with refractive surgery if available.^23,24 The Royal Australian College of General Practitioners’ (RACGP’s) Guidelines for preventive activities in general practice (Red Book) recommends assessment of visual acuity in Australians from 65 years of age if requested or symptomatic.⁷
The substantially higher prevalence and under-diagnosis of vision impairment in Aboriginal and Torres Strait Islander peoples, along with poorer access to corrective services, warrants routine visual acuity screening in all age groups in this population. An eye examination is a mandatory requirement for a ‘Medicare Health Assessment for Aboriginal and Torres Strait Islander Peoples Health Assessment’ (MBS item 715; refer to ‘Resources’),²⁵ and this is supported by recommendations in the CARPA standard treatment manual (7th edn) and the Queensland Chronic conditions manual.^19,20

Testing vision

The standard (Snellen) eye chart and tumbling E chart are the most suitable tools to assess visual acuity.²⁰The CRANAplus Remote primary care manual also includes the option of using Lea charts.²⁶ Screening questions are not as accurate as visual acuity testing for identifying visual acuity impairment.^27,28 The E-test visual acuity charts for near and distance vision are useful for people who cannot read Roman letters²⁹ and were used routinely in the NIEHS.⁴ The need to test near or ‘reading’ vision, especially in those aged over 40 years, is of even greater importance. Near vision test cards or in fact any printed matter can be used to test near vision, and E-tests for near vision can also be used for the those who cannot read.²⁶

Cataract

Cataract surgery has been shown to improve vision^27,30 and quality of life,³⁰ and reduce the risk of car crash^31,32 and the rates of falls in older people.^33,34 A case record audit in the Northern Territory (NT) found cataract surgery had a beneficial effect on visual acuity and quality of life for Aboriginal and Torres Strait Islander people.³⁵ Risk factors for cataract include age,^36–38 cumulative ocular exposure to ultraviolet light,^36–40 diabetes and poor diabetic control,^37,41 smoking,^36–38,42 alcohol use,^37,38 family history of cataract, ocular injury, use of corticosteroids and high myopia.³⁷ Although exposure to sunlight accounts for only 10% of cataracts in urban, non-tropical Australian settings,⁴⁰ this risk factor may be more important in northern Australian populations. Data collected from the NIEHS showed that approximately 20% of Aboriginal and Torres Strait Islander respondents reported never wearing sunglasses or a hat and that use of sun protection was significantly lower in people in the NT compared with New South Wales and in people living in remote and very remote areas compared with urban areas.⁴³ The Specialist eye health guidelines for use in Aboriginal and Torres Strait Islander populations recommends decreased exposure to ultraviolet B light and cigarette smoking to prevent cataract.³⁸ A diet high in fruit and vegetable intake is associated with a lower risk of developing cataract,³⁷ and a recent meta-analysis indicated a clinically relevant reduction in cataract incidence associated with statin use.⁴⁴

Diabetic retinopathy

The overall prevalence of DR in those with known diabetes in Australia is around 25%.^45–47 The crude prevalence is similar between Aboriginal and Torres Strait Islander and non-Indigenous populations.⁴⁷ However, as diabetes is far more prevalent among Aboriginal and Torres Strait Islander Australians, the proportion of those affected by DR across these peoples should be considerably higher when compared with non-Indigenous Australians.⁴⁵ Around 8% of Aboriginal people living in Central Australia with diabetes have vision-threatening DR,⁴⁵ and the annual incidence of DR among patients with diabetes in Central Australia is approximately 9%.⁴⁸

Duration of diabetes is the strongest factor determining DR prevalence;^38,49–51 however, early onset DR (within 10 years of onset of diabetes) is more common in Aboriginal and Torres Strait Islander peoples than in non-Indigenous people.³⁸ The most important systemic factors associated with increased risk of DR are
poor glycaemic control,^{38,45,49,50,52} hypertension,^38,50,52 dyslipidaemia^38,50,52 and renal impairment.^50,52 There is a possible association with alcohol and the development of diabetic retinopathy.³⁷

Pregnancy is an independent risk factor for worsening of DR.^38,50,53 Progression of retinopathy occurs at approximately double the rate in pregnant women compared with non-pregnant women and is a leading cause of blindness in women who have pre-existing diabetes during their childbearing years.⁵³
Current Australian recommendations are that all Aboriginal and Torres Strait Islander people with diabetes have visual acuity and retinal assessment (by dilated fundus examination or retinal photography) at the diagnosis of diabetes, and then yearly.^47,50,54 Establishing an effective referral process for those with retinopathy is important. People with diabetes may have refractive error and are at increased risk of developing cataract. Screening and referral pathways for these conditions are also important in providing appropriate eye care for those with diabetes.

Regular follow-up with early detection and timely treatment of vision-threatening retinopathy enables the prevention of up to 98% of visual loss.^50–52,55 Those at high risk (poor glycaemic control, hypertension, dyslipidaemia and longer duration of diabetes), should be screened annually.^47,50,54,56 Screening for children with diabetes should begin at puberty unless clinical concerns become apparent before this.^47,50,54 Mydriatic or non-mydriatic retinal photography screening has been shown to be an effective alternative to dilated fundus examination^50,57–59 and is being used routinely in some isolated areas of Australia with support through telemedicine.⁵⁴ A new MBS item number for assessment of visual acuity and retinal photography with a non-mydriatic retinal camera for Aboriginal and Torres Strait Islander people with diabetes for use in general practice became available in November 2016 (MBS item 12325; refer to ‘Resources’).^25,54

Good glycaemic,^{38,47,50,52,60–64} lipid^52,62,63 and blood pressure^{38,47,50,52,61–63} control, together with regular eye examinations and early treatment of any diabetic retinopathy, remain the cornerstone of primary prevention and delay of progression of diabetic retinopathy.^47,50,63,65 These measures also increase the length of life, so do not reduce the lifetime risk of developing retinopathy.

Once DR is detected, further examinations by an optometrist or ophthalmologist should be conducted annually or at three-monthly to 12-monthly intervals, depending on the level of DR. Any new visual symptoms should prompt consideration of specialist referral.^47,50 Urgent ophthalmology referral (within four weeks) is recommended if any of the following are suspected: diabetic macular oedema (DME), proliferative diabetic retinopathy (PDR) or an unexplained fall in visual acuity.⁵⁰

For women with pre-existing diabetes who become pregnant, a first trimester eye examination, either by dilated fundus examination or retinal digital imaging, is recommended.^50,52,53,66 Many guidelines also recommend preconception counselling about the risks of DR and eye examination for women with pre-existing diabetes who are planning pregnancy.^52,53,61,66 Rapid optimisation of previously poor glycaemic control in pregnancy should be deferred until after retinal assessment for women with pre-existing diabetes.⁶¹ For pregnant women with pre-existing diabetes, retinal examinations in the second and third trimester are also recommended by most guidelines, depending on findings in earlier examinations.^50,52,53,66 Evidence indicates a need for ophthalmic follow-up for 6–12 months postpartum for women who had diabetes prior to pregnancy.^52,53,61 Women with gestational diabetes do not require screening because their risk of diabetic retinopathy does not increase during pregnancy.⁵²

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

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